2. Broward General Medical Center Level I Trauma Center
Michael W. Parra, MD
Director of Trauma Critical Care Research
Director of the International Trauma Critical Care Improvement Project
Clinical Assistant Professor/NOVA Southeastern University
Broward General Level I Trauma Center
Fort Lauderdale, FL

3. H & P 80 yo F s/p MVC Restrained driver T-boned on driver side No LOC
Complaining of left sided hip pain
PmedHx:
Hypothyroidism
HTN
CAD
Hypercholesterolemia

4. H & P Meds: Psurg Hx: Levothyroxine Imdur Atenolol Protonix Zocor HCTZ
Diovan
Psurg Hx:
Cardiac Stents x 2 in 2001

5. Prehospital Vital Signs at Scene:
RR: 16
BP: 122/77
GCS: 15 AAOx3
Inmobilized with C-collar and Back Board
Total IVF given 200 cc NS
Tranported via ground to Level I Trauma Center
Total transport time less than 15 minutes

6. Level I Trauma Bay
Primary and Secondary Survey only reveal pubic tenderness
Vital Signs:
P: 96
RR: 21
BP: 110/82
O2 Sat: 94% on 2 Lt NC
GCS: 15

7. Level I Trauma Bay Initial Work Up:
Trauma Labs including cardiac enzymes
H/H: 10/30
Plts: 136
PT/PTT: 12/21
PCXR
AP Pelvic XR: Bilateral Superior and Inferior Rami Fractures
12 Lead EKG = NSR with RBBB

8. Level I Trauma Bay Patient becomes hemodinamically unstable
Vital Signs:
P: 110
RR: 24
BP: 66/32
FAST performed by trauma surgeon: Negative

9. Level I Trauma Bay “Damage Control Resuscitation” initiated:
2 U PRBC’s transfused
Hemodinamically Unstable Pelvic Fracture Protocol initiated:
TPOD placed
Patient Responds hemodinamically to initial resuscitation efforts
STAT CT Abd/Pelvis: Active extravasation of contrast

10. Level I Trauma Bay Patient taken immediately to Angio Suite
Pelvic Angiogram performed via Rt femoral artery access
“Damage Control Resuscitation” continued in Angio Suite:
2 more Units PRBC’s
2 units of FFP

11. Level I Trauma Bay
Pelvic Embolization (PE) Left Hypogastric Branch - 5 coils
Patient remains hemodinamically unstable
Patient taken immediately from angio suite to the OR for Preperitoneal Pelvic Packing for control of presumptive ongoing venous pelvic bleeding

12. OR Supraumbilical Exploratory Laparotomy
Infraumbilical Preperitoneal Pelvic Packing
On Table Retrograde Cystogram with Methillin Blue

13. OR
Elap Negative
On Table Cystogram with no intra o extraperitoneal extravasation of dye
“Damage Control Resuscitation” totals:
6 Units PRBC’s
3 Units FFP
1 Pack of Platelets
1 Unit of Cryoprecipitates
400 cc NS

14. PPP & PE

15. Post-Op Transferred to the ICU Patient rewarmed to a temp of 37C
Extubated later that same day
H/H remained stable at 10/30
Pelvic Packing removed 36 hours later in the OR

16. Post-Op
Patient taken on POD#5 for ORIF of pelvic fractures by Ortho Service
Patient recovers well and is eventually discharged to Rehab

17. Abstract Being Presented At The 2010 Panamerican Trauma Symposium Montevideo/Uruguay
Title:
Institutional Review and the Implementation of a New Algorithm for the Treatment of Hemodynamically Unstable Pelvic Fractures

18. 2010 Panamerican Trauma Symposium Abstract
Purpose: Evaluation of the current treatment modalities at our local trauma centers of hemodynamically unstable pelvic fractures, and the proposal of an algorithm for their management that consists of initial immobilization with a pelvic orthotic device
(T-POD) and preperitoneal pelvic packing (PPP) in conjunction with angio-embolization

19. 2010 Panamerican Trauma Symposium Abstract
Method: Retrospective review from of hemodynamically unstable pelvic fractures at two regional trauma centers: Delray Level II Trauma Center and Broward General Level I Trauma Center

20. 2010 Panamerican Trauma Symposium Abstract
Results:
A total of 50 patients sustained pelvic fractures and underwent pelvic angiography for ongoing hemodynamic instability and presumptive active arterial or venous pelvic bleeding
Ten patients were excluded due to the discovery of an alternate source of bleeding that required operative repair
The most common alternate sources of bleeding were liver and splenic lacerations
Of the remaining 40 patients, the male to female ratio was 1.7:1

21. 2010 Panamerican Trauma Symposium Abstract
Results:
Mean age was 49, ranging from 17-91
The mean ISS score was 24, ranging from 4-75
The mean lowest systolic blood pressure was 78.5 ranging from
The most common mechanism of injury was:
motor vehicle crash (48%)
pedestrian hit by car (24%)
falls (12%)
motorcycle crashes (7%)

22. 2010 Panamerican Trauma Symposium Abstract
Results:
Fifteen (37%) patients had positive angiograms and underwent selective pelvic embolization
The remaining 25(63%) patients had presumptive pelvic venous bleeding
Only 6 (15%) patients underwent pelvic immobilization with a T-POD in the trauma bay and 4 (67%) of them survived
Six (15%) patients had PPP, and 4 (67%) of them survived
Only two patients had both T-POD and PPP, and both survived to discharge

23. 2010 Panamerican Trauma Symposium Abstract
Conclusion:
The therapeutic combination of a pelvic orthotic device and preperitoneal pelvic packing added to a multi-interventional resuscitation algorithm might be life saving in patients with life-threatening pelvic injury
Our retrospective institutional review has revealed an under utilization of both pelvic immobilization and damage control pelvic bleeding techniques
We propose the following algorithm for the management of such patients and the evaluation of its effectiveness prospectively at our regional trauma centers

24. Yes No Unstable Stable Stable Unstable Stable Unstable
Positive Equivocal Negative